Stent ISR Treated Using Rotablation and DEB

- Operator : Seung-Jung Park

Stent ISR Treated Using Rotablation and DEB
- Operator: Seung-Jung Park, MD
Case Presentation
A 75-year-old female patient was admitted to our center for thallium SPECT abnormality for regular surveillance . She underwent PCI at LAD 22 years ago. 10 years later, ISR at LAD was identified on follow-up CAG but she refused to take PCI. Instead, she was regularly followed as outpatient with medications. Her coronary arterial risk factor was hypertension. The physical examination and electrocardiogram were unremarkable. Echocardiography revealed normal left ventricular systolic function without regional wall motion abnormality. Thallium SPECT stress image revealed mild to moderately decreased perfusion in apicolateral, mid anterior wall.
Baseline Coronary Angiogram
  1. The right coronary angiogram showed diffuse stenosis at RCA ( Movie 1, Movie 2).
  2. The left coronary angiogram showed diffuse progression of ISR with heavy calcification in the previous stent at pmLAD and tight stenosis at distal LCX ( Movie 3, Movie 4).
Procedure
An 8 Fr long sheath was inserted through the right femoral artery and left coronary artery was engaged with an 8 Fr JL 4 guiding catheter. The wire, 0.014-inch BMW was inserted into the LAD with the help of Caravel micro-catheter. We decided to perform rotablation for heavily calcified ISR lesion. A 0.014 inch Rotawire was inserted through Caravel micro-catheter and stepwise rotablation was done with 1.5 mm burr ( Movie 5). While rotablation, atropine was injected because the patient developed hypotension and bradycardia. After rotablation, we changed a 0.014 inch Rotawire into a 0.014 inch BMW wire and pre-dilatation at mLAD and pmLAD was performed with a Sapphire NC 2.75 x18 mm balloon ( Movie 6). After pre-dilatation, we deployed a Xience Alpine stent 2.75 x 18 mm at the mLAD ( Movie 7). Post-stenting adjunctive balloon dilatation with a Sapphire NC 2.75 x18 mm balloon was done ( Movie 8). Then DEB (SeQuent Please 3.5 x 26 mm) was applied at pmLAD ISR lesion ( Movie 9). The final angiogram showed successful results of the procedure ( Movie 10).

Appendix
LAD IVUS image of post-rotablation ( Movie 11), post-stent ( Movie 12), and final image ( Movie 13)

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